Spirituality & Health:
Current Trends
in the Literature
and Research
Chaplain John Ehman
University of Pennsylvania Medical Center –
Penn Presbyterian
The Rise of
Spirituality & Health
as a Recent Stream of
Thought & Research
in Health Care
Number of Medline-Indexed English
Articles by Year (1980-2007), with Keywords
RELIGION, RELIGIOSITY, RELIGIOUS
or RELIGIOUSNESS
1600
1400
1200
1000
800
600
400
200
19
80
19
82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
98
20
00
20
02
20
04
20
06
0
John Ehman, 6/30/09
Number of Medline-Indexed English
Articles by Year (1980-2007), with Keywords
SPIRITUAL or SPIRITUALITY
800
700
600
500
400
300
200
100
19
80
19
82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
98
20
00
20
02
20
04
20
06
0
John Ehman, 6/30/09
Number of Medline-Indexed English Articles by
Year (1980-2007), with TITLES Using the Terms
Religion/Religiosity/Religious/Religiousness
and Spiritual/Spirituality
300
250
200
150
100
50
19
80
19
82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
98
20
00
20
02
20
04
20
06
0
John Ehman, 6/30/09
What’s behind the surge of
activity since the mid-1990s?
A short answer:
Health Care providers and researchers have
become interested in spirituality/religion as a
proper subject for scientific investigation, and
(to a lesser extent) chaplains have become
interested in scientific investigation as an
important “way of knowing” for pastoral work.
Religion & Mental Health Research up to 2000:
Quantitative Studies Showing Positive Effects
• Purpose and meaning in life
15 of 16
• Well-being, hope, and optimism
91 of 114
• Social support
19 of 20
• Marital satisfaction and stability
35 of 38
• Depression and its recovery
60 of 93
• Suicide
57 of 68
• Anxiety and fear
35 of 69
• Substance abuse
98 of 120
• Delinquency
28 of 36
TOTAL
--Koenig, et al., Handbook of Religion and Health, 2001
478 of 724
Religion & Physical Health Research up to 2000:
Quantitative Studies Showing Positive Effects
•
•
•
•
•
•
•
•
•
•
Better immune/endocrine function
Lower mortality from cancer
Lower blood pressure
Less heart disease
Less stroke
Lower cholesterol
Less cigarette smoking
More likely to exercise
Lower mortality
Clergy mortality
TOTAL
--Koenig, et al., Handbook of Religion and Health, 2001
5
5
14
7
1
3
23
3
11
12
of
of
of
of
of
of
of
of
of
of
5
7
23
11
1
3
25
5
14
13
84 of 107
Religion & Mortality in Cardiac Patients
1995 study of 232 elective heart surgery patients
Those who did not find "strength and comfort"
in religious faith were almost 3 times more
likely to die within 6 months than those who
indicated at least some "strength and comfort.“
(This was a consistent predictor of mortality
in multivariate analyses.)
None of the 37 patients who said they were
"deeply" religious had died 6 months post-op.
--Oxman, et al., "Lack of social participation or religious…,“
Psychosomatic Medicine 57, no. 1 (Jan-Feb 1995): 5-15.
Early Intervention Study Using Chaplains
Orthopedic surgery patients divided into 3 groups:
"support," "support + information," and a control.
• The "support" group had shorter LOS, lower
post-op anxiety, used less pain medication, and
made fewer calls for service. (Effects were slightly
greater for the "support + information" group.)
• Patients receiving pre-op emotional support had
higher pre-op anxiety than did members of the
control group –but lower post-op anxiety
--Florell, J. L., "Crisis Intervention in Orthopedic Surgery—
Empirical Evidence of the Effectiveness of a Chaplain
Working with Surgery Patients," Bulletin of the American
Protestant Hospital Assoc. 37, no. 2 (1973): 29-36
Ways of Knowing
The Emerging
Conceptualization of
Spirituality
in the
Health Care Literature
Streams of Thought about Spirituality
Theologians
Dogmatists
“Folk
Tradition”
Philosophers
Social
Scientists
Clinicians
The Potentially Significant Influence of
Clinicians’ Thinking about Spirituality
• It can be rapidly institutionalized (directly in health care
systems and in cooperation with government systems)
• It can quickly develop a tradition, establishing its own
“canon” through the health care journal literature
• It can affect people at crucial times in their lives (during
health care crises)
• It carries the authority of science and the integrity of
medicine (and can be conveyed personally in the
physician-patient relationship)
• It can be relatively independent of other traditional
streams of thought about spirituality
Spirituality is often defined vis-à-vis religion.
Note the etymologies:
SPIRITUALITY
…from the Latin meaning “to breathe”
RELIGION
…from the Latin meaning “to bind”
(likely connected with a context of
piety or consecration)
The Two Most Common Views of the
Relationship of Spirituality to Religion
in the Current Health Care Literature
Spirituality
Spirituality
Religion
Religion
From the Author of the FICA Assessment:
“I see spirituality as that which allows a person
to experience transcendent meaning in life.
This is often expressed as a relationship with
God, but it can also be about nature, art, music,
family, or community—whatever beliefs and
values give a person a sense of meaning and
purpose in life. …Patients learn to cope with
and understand their suffering through their
spiritual belief, or the spiritual dimension of
their lives”
--Christina Puchalski and Anna L Romer, “Taking a Spiritual
History…,” J of Palliative Med 3, no. 1 (Spring 2000): 129.
The emerging character of spirituality as
a concept in the health care literature:
• interest in inclusivity and diversity
• interest in going beyond the “limits” of religion
• focus on the here-and-now, individual, human
experience (--concept not essentially theistic)
• focus on pragmatic value (e.g., coping)
• concept largely influenced by the health care
context (especially regarding serious illness)
• concept accepted as somewhat ambiguous
Key Problems
in
Spirituality & Health
Research
Ambiguity of
Terms and Concepts
Spiritual/religious terms and concepts
are loosely defined and have various
meanings within different theological
and cultural traditions.
Working Across
Cultural Contexts
Because spirituality/religion is deeply
rooted in cultural contexts, it is hard
to standardize studies or generalize
findings across the different contexts.
Qualitative vs. Quantitative
Descriptive vs. Interventional
_
_
_
Funding and publication favors
quantitative-interventional studies,
but qualitative-descriptive studies
are still needed to lay a foundation
for this young field of inquiry.
Measures: Trait vs. State;
How to Capture Change
_
_
_
Most measures in the field capture
spiritual traits and thus do not
measure spiritual change.
Size of Effect
The effect of spirituality on health,
or of health on spirituality, may
be significant but not dramatic
(and thus hard to capture).
Mechanism of
Cause and Effect
The way that spirituality affects
health, or health affects spirituality,
appears to be complex.
Theoretical Model of How Religion Affects Physical Health
--adapted from Koenig, et al., Handbook of Religion and Health, 2001
R
E
L
I
G
I
O
N
Mental
Health
Social
Support
Health
Behaviors
Religion also affects Childhood Training,
Adult Decisions, and Values & Character;
which then in turn affect mental health,
social support, and health behaviors.
Stress
Hormones
Infection
Cancer
Immune
System
Autonomic
Nervous
System
Disease Detection
and Treatment
Compliance
High Risk
Behaviors
(smoking, drugs)
Heart
Disease
Hypertension
Stroke
Stomach
& Bowel
Liver
& Lung
Accidents
& STDs
NOTE:
All measures/studies
of spirituality & health
involve theologically
relevant assumptions
Cooperation of Subjects
Cooperation of subjects is especially
problematic, since religion/spirituality
is not only a deeply personal issue but
a socially and politically powerful one.
Three General Approaches
in
Spirituality & Health
Research
Recent studies have tended
to focus on spirituality as:
1) a ground for “religious” social support
2) a value basis for personal meaning-making
[and therefore understanding illness and
coping with crises] and decision-making
3) a context for behavior that can influence the
way the body works (e.g., meditation that
can affect physiological reactions to stress)
Religious Attendance & Healthy Behavior
In a large sample of adults living in Alameda, CA,
followed from 1965-1994:
Those attending religious services weekly were more likely
than those who attended less or not at all to develop
healthy behaviors (e.g., quit smoking, become often
physically active, or increase the number of personal
relationships) and to keep from developing unhealthy
behaviors (e.g., stop medical checkups or reduce
individual relationships).
--Strawbridge, et al., “Religious Attendance Increases
Survival…,” Annals of Behavioral Medicine 23, no. 1
(2001): 68-74.
Treatment Decision Factors
Ranking of the importance of treatment decision
factors by oncology patients and oncologists:
PATIENTS
1) Cancer Dr’s recommend.
2) Faith in God
3) Ability to cure
4) Side effects
5) Family Dr’s recommend.
6) Spouse’s input
7) Children’s input
ONCOLOGISTS
1) Cancer Dr’s recommend.
2) Ability to cure
3) Side effects
4) Spouses’ input
5) Family Dr’s recommend.
6) Children’s input
7) Faith in God
--Silvestri, et al., “Importance of faith on medical decisions…,”
J of Clinical Oncology 21, no. 7 (April 1, 2003): 1379-1382
Physician Inquiry re: Patients’ Spiritual Beliefs
A Penn study of 177 pulmonary outpatients indicated:
• Nearly half of patients may have spiritual/religious
beliefs that would influence their health care
decision-making if they became gravely ill.
• Two-thirds of patients would welcome a carefully
worded exploratory question about spiritual or
religious beliefs. (E.g., “Do you have spiritual or
religious beliefs that may affect your medical
decisions?”)
• Two-thirds of patients think that such an inquiry by a
physician would make them trust the physician more.
--Ehman, J. W., et al., “Do patients want physicians to inquire…,
Archives of Internal Medicine 159, no. 15 (1999): 1803-1806
Religious Dietary Laws & Medication Usage
Small British study of Muslim patients who
are observant of Islamic dietary laws
• Only 26% said they'd take medication if they were
unsure whether it was halaal
• 42% said they'd not take medication if they were
unsure whether it was halaal
• 58% said they'd stop taking medication if they
found out it was haraam
• Only 8% thought it was acceptable to take haraam
medications for minor illnesses, but 36% thought
it acceptable to take haraam medications for
major illnesses.
--Bashir, et al., "Concordance in Muslim patients…," Int'l J of
Pharmacy Practice 9, no. 3 Suppl (September 2001): R78.
Spirituality & the Brain
Brain scans of Buddhist monks who practiced
meditation in the scanner showed significant changes
in cerebral blood flow during meditation.
• There was a significant increase in activity
in the frontal lobes (involved in focusing
attention and concentration)
• The increase in activity in the frontal lobes
was significantly correlated with a decrease
in activity in the left superior parietal lobe
(involved in orientation in time and space)
--Newberg, et al., "The measurement of regional cerebral
blood flow…, Psychiatry Research: Neuroimaging 106,
no, 2 (April 10, 2001): 113-122.
Frontal Lobe Activity of Buddhists Meditating
--see Newberg, et al., "The measurement of regional cerebral blood flow…,”
Psychiatry Research: Neuroimaging 106, no, 2 (April 10, 2001): 113-122.
Parietal Lobe Activity of Buddhists Meditating
--see Newberg, et al., "The measurement of regional cerebral blood flow…,”
Psychiatry Research: Neuroimaging 106, no, 2 (April 10, 2001): 113-122.
Religious Coping
and
Religious Struggle
Assessment Terminology in Medline-Indexed Articles
(1997-2007)
150
140
130
120
110
100
90
80
70
60
50
40
30
20
10
0
Pain
Distress
Suffering
Struggle
Spiritual
Crisis
Problem
Religious
Coping
Existential
Strength
Growth
Resourc?
Religion & Mental Health
Study of 406 mental health patients in Los Angeles
• 80% reported using some type of religious activity
or belief to cope with symptoms or daily difficulties
• 30% said their religious beliefs or activities “were
the most important things that kept them going”
• Both the number of years that patients had used
religious coping and the proportion of coping
devoted to religious coping beliefs or practices
were correlated with less severe symptoms and
better overall functioning.
--Tepper, et al., "The Prevalence of Religious Coping…,"
Psychiatric Services 2001 52, no. 5 (May 2001): 660-665.
Spirituality & PMV Survivors
Seven survivors of prolonged mechanical ventilation
were asked, "What is it like to experience survival
from prolonged mechanical ventilation?"
Six themes emerged by qualitative analysis:
• endures a traumatic experience
• relies on self-determination
• credits family support and devotion
• finds comfort through religion and prayer
• praises health care professionals
• derives reassurance from angelic encounters
--Arslanian-Engoren & Scott, "The lived experience…,"
Heart & Lung 32, no. 5 (Sep-Oct 2003): 328-334.
Patients’ Use of Prayer for Pain Control
A cross-sectional sample of 157 inpatients were asked:
“Which of the following pain control methods (if any)
have you used since you were admitted?”
Pain Pills
Prayer
Pain Meds in IV
Pain Injections
Relaxation
Distraction
PCA Pump
Heat Application
Touch
Cold Application
67% said “yes”
62
54
51
27
[top 10 answers
24
from 17 choices]
21
18
16
13
--McNeill, et al., “Assessing Clinical Outcomes…,” J of
Pain & Symptom Management 16, no. 1 (1998): 29-40.
Spirituality & Pain
A study of college-age students who were taught either
a spiritual meditation, secular meditation, or relaxation
technique; which they practiced for 20-minutes a day
for 2 weeks.
The spiritual meditation group was able to tolerate an
induced pain experience* almost twice as long as did
the other two groups, though pain perception was
reportedly not altered.
--Wachholtz & Pargament, "Is spirituality a critical ingredient…,“
J of Behavioral Medicine 28, no. 4 (August 2005): 369-384.
* Holding one’s hand in a cold water bath of 2°C
Meditation Intervention with Migraine Sufferers
83 participants in 4 groups: Spiritual Meditation, Internal
Secular Meditation, External Secular Meditation, and
Relaxation; with each group practicing for one month.
The Spiritual Meditation group showed the greatest
reduction in headache frequency, increase in pain
tolerance, drop in negative affect, decrease in trait
anxiety, increase in headache self-efficacy, and
increase in daily spiritual experiences.
No differences in positive affect, depression,
migraine-specific quality-of-life, or Spiritual WellBeing/Religious Well-Being.
Wachholtz & Pargament, "Migraines and Meditation: Does Spirituality
Matter?" J. of Behavioral Medicine 31, no. 4 (Aug 2008): 351-366.
Religious Struggle & Mortality
2-year longitudinal study of 596 patients; 176 died
Brief RCOPE items significantly associated with an
increased risk of dying:
- Wondered whether God had abandoned me (28%)
- Questioned God’s love for me (22%)
- Decided the devil made this happen (19%)
Overall, Brief RCOPE indicators of “religious struggle”
were associated with only a 6%-10% increased risk of
mortality, but the effects remained significant even after
controlling for a number of confounding variables.
--Pargament, et al., "Religious coping methods as
predictors…," Archives of Internal Medicine 161,
no. 15 (August 13-27, 2001): 1881-1885.
Religious Coping & Mortality
[further analysis of the Pargament, et al. 2-year data]
When the sample was broken down into four groups:
negative religious coping at baseline & follow up
- chronic negative religious copers
- transitory negative religious copers
- acute negative religious copers
- non-negative religious copers
yes
yes
no
no
yes
no
yes
no
Only chronic negative religious copers showed greater
risk for poorer health outcomes: they declined in indices
of quality of life and became somewhat more depressed
and physically dependent. [--see p. 724]
--Pargament, et al., “Religious coping methods as predictors…,”
J of Health Psychology 9, no. 6 (November 2004): 713-730.
Prevalence & Correlates of Spiritual Struggle
Studies of diabetic, congestive heart failure, and
oncology patients, using the Brief RCOPE.
• 15% indicated a level of spiritual struggle that
might risk of poor mental or physical outcomes
• Age was inversely related to negative religious
coping scores
• Higher levels of positive religious coping were
associated with higher levels of negative religious
coping, except for those with mid-range positive
religious coping scores.
--Fitchett, et al., "Religious struggle: prevalence…," Int'l
J of Psychiatry in Medicine 34, no. 2 (2004): 179-196.
Where do we go from here?
Measurable dimensions of religion/spirituality
that appear to be functionally related to health:
•
•
•
•
Perceived closeness to God
Religion/spirituality as orienting & motivating
Religious support
Religious/spiritual struggle
Future needs for religion/spirituality measures:
•
•
•
•
More culturally sensitive measures
Alternatives to self-report measures
Measures of religious/spiritual outcome
Measures of religious/spiritual change
--Hill & Pargament, “Advances in the Conceptualization
and Measurement of Religion and Spirituality…,”
American Psychologist 58, no. 1 (Jan 2003): 64-74.
Continue to use the scientific
process as a Way of Knowing…
…recognizing that it is a Way of Knowing
that 1) builds knowledge slowly -- bits at
a time -- and that 2) requires patience,
attention to fine details, and caution
about drawing conclusions.
The Association for Clinical Pastoral Education (ACPE)
Research Network offers a variety of bibliographic
and other resources:
www.ACPEresearch.net
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------
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The University of Pennsylvania Health System
Department of Pastoral Care publishes annual
bibliographies of Medline-indexed articles
relating to spirituality & health:
www.uphs.upenn.edu/pastoral
(See the section on Research & Staff Education.)
john.ehman@uphs.upenn.edu